Cycle helmet ownership and wearing; results of a survey in South Staffordshire

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1 Joural of Public Health Medicie Vol.20,. 1, pp Prited i Great Britai Cycle helmet owership ad wearig; results of a survey i South Staffordshire Sue Wardle ad Zafar Iqbal Abstract Backgroud Despite icreasig evidece idicatig that wearig cycle helmets ca reduce the severity of head ijuries, particularly i childre, there is a paucity of local data o cycle helmet owership ad wearig rates. These data together with a uderstadig of the factors which ifluece these rates are importat i developig appropriate health promotio programmes. Method The objectives were to (1) establish patters of cycle helmet owership ad wearig rates, ad (2) determie factors ifluecig these rates. A descriptive survey ivolvig a self-completed questioaire was udertake ad a series of focus groups were also established. The settig was two high schools ad four primary schools i each of the six boroughs or district coucils withi South Staffordshire ivolvig 932 Year 6 ad 2005 Year 10 childre. Results The respose ratio was 70.9 per cet from Year 6 ad 80.9 per cet from Year 10, givig a overall respose rate of 77.8 per cet. Most childre (86.6 per cet) rode a bicycle ad of these 42.8 per cet owed a cycle helmet. Just over a third (36.8 per cet) of Year 6 cyclists wore a helmet always or early always, compared with 13.7 per cet of Year 10 cyclists. Although the protective effect of cycle helmets was appreciated, may childre did ot see themselves as beig persoally at risk, particularly o short joureys. The appearace ad comfort of the helmet appeared to be stroger factors ifluecig the uptake of helmets compared with cost. Both year groups were similarly cocered with comfort, but Year 10 childre appeared more cocered with appearace tha Year 6 childre. Coclusios Cycle helmet owership ad wearig is still disappoitigly low, especially amogst older childre. The factors ifluecig patters of owership ad wearig are umerous ad the iterrelatioships betwee them are complex, requirig a co-ordiated approach from a rage of agecies. Cycle helmet legislatio should be cosidered by the Govermet. Keywords: cycle helmets, ijury prevetio Backgroud It is widely ackowledged that cyclig has substatial health ad social beefits. Natioally, the umber of cycle-owig households is growig. However, cyclists are vulerable, beig especially at risk of head ijury. 1 Although there is still some debate, 2 most commetators agree that wearig of a cycle helmet ca reduce the severity of head ijuries, especially i accidets that do ot ivolve aother vehicle. 3 ' 4 Therefore, it is importat to promote activities that facilitate safe cyclig, such as cycle laes ad the use of cycle helmets. Despite the growig cosesus that helmets do save lives, there is a lack of local data o cycle helmet owership ad wearig rates. A iteratioal literature review of cycle helmets prepared by the Trasport Research Laboratory 5 revealed oly three UK research projects that examied cycle helmet owig ad/or wearig amogst childre. Furthermore, little is kow about the reasos for o-owership or o-wearig, although expese is oe commoly assumed factor. Therefore, it was decided to udertake a multi-agecy research project ivolvig Staffordshire Couty Coucil Road Safety Uit, the Directorate of Public Health ad Health Policy ad the Health Promotio Uit of South Staffordshire Health Authority, to examie cycle helmet owership ad wearig rates amogst childre. Both quatitative ad qualitative data were collected. The aims of this study were (1) to be able to describe the size of helmet wearig populatio ad its characteristics, ad (2) to supplemet this by obtaiig more iformatio o the reasos for various behaviours. Such data are importat to desig cycle helmet promotio schemes, to assess the eed for low-cost cycle helmet schemes ad to use as baselie data to moitor the success of future health promotio campaigs. Subjects ad methods Subjects South Staffordshire is a large, relatively affluet 'Middle Eglad' district. The survey populatio of iterest were childre withi the district who owed ad rode a bicycle. To obtai a sample from this populatio, childre attedig a Directorate of Public Health ad Health Policy, South Staffordshire Health Authority, Mellor House, Stafford ST16 3SR. Sue Wardle, Epidemiologist Zafir Iqbal, Cosultat i Public Health Medicie Address correspodece to Ms Sue Wardle. Oxford Uiversity Press 1998

2 CYCLE HELMET WEARING 71 school i South Staffordshire were used. Previous research shows 5 ' 6 that both owership ad wearig rates differ with school age. To allow for chages i kowledge, attitude ad behaviour with age, two school year groups were selected for study: Year 6 (maily 10- ad 11-year-olds) ad Year 10 (maily 14- ad 15-year-olds). Quatitative survey Resources did ot allow for a probability sample to be selected, but to obtai as represetative a sample as possible, two high schools ad four primary schools were selected i each of the six boroughs or district coucils withi the Health Authority area (36 schools i total). These schools were selected o the basis of data o percetage of free school meals, i.e. oe high school ad two primary schools were selected i each area that had the highest percetage of free school meals, ad similarly for schools havig the lowest percetages of free school meals. The iformatio o free school meals was provided by the Local Educatio Authority, through their Teacher Advice for Persoal, Social ad Health Educatio. The above selectio process idetified samples of 932 Year 6 ad 2005 Year 10 childre. A self completio questioaire was developed to collate iformatio o cycle helmet wearig. The questioaire was piloted i oe school (ot icluded i the sample) ad, as a result, some amedmets were made. The questioaire was completed aoymously by Year 6 ad Year 10 childre durig the class time i the Sprig Term of Teachig staff collected the questioaires ad retured them i a large prepaid evelope. A period of three weeks was allowed for this. As it was ot plaed to aalyse the results of the survey usig free school meal status, the questioaires were ot coded ad their free school meal status could ot subsequetly be idetified. Focus groups Focus groups were coducted i six primary schools amogst Year 6 childre ad i four secodary schools amogst Year 10 childre. The schools chose were those that had bee particularly helpful regardig other accidet prevetio work. Each group comprised about six bicycle riders ad usually icluded both males ad females. The groups were coducted i iformal situatios such as commo rooms, cafeterias or the school hall. Each discussio lasted aroud 20 miutes with a Health Promotio Officer as facilitator usig a set of predefied questios for discussio. All the discussios were taped, ad afterwards trascribed usig the pre-defied questio sheet. Neither the quatitative or the qualitative survey collected data o the frequecy or the cotext (recreatio or trasport) of pupils' ridig behaviour. Although importat, we were kee to keep the questioaire ad focus group discussios to a miimum ad so did ot iclude these subjects. Results Quatitative survey - questioaire o cycle helmet wearig ad owership Respose I total, 2284 questioaires were received with a overall respose ratio of 77.8 per cet: 70.9 per cet from Year 6 (661/ 932) ad 80.9 per cet from Year 10 (1623/2005). Just over half of the respoders were boys (54.7 per cet, = 1249); (45.3 per cet, = 1034) were girls (oe child did ot aswer this questio). Childre were asked first if they rode a bicycle; 86.6 per cet ( = 1965) said they did ad the remaiig 13.4 per cet ( = 305) said they did ot. The followig aalysis cocetrates o those ridig a bicycle ad therefore beig at risk of a head ijury from a cycle accidet. Cycle helmet owership ad wearig (see Fig. 1) Overall 42.8 per cet ( = 842) of cycleriderssaid they owed a cycle helmet ad 57.2 per cet ( = 1127) said they did ot. There was a higher prevalece of helmet owership amogst youger, male cycle riders: 61.1 per cet of boys ad 53.6 per cet of girls i Year 6, compared with 40.2 per cet of boys ad 29.9 per cet of girls i Year 10. The gap wideed with icreasig age. Childre who owed helmets were asked if they wore them always, early always, sometimes or ever. Nearly two-thirds of youger childre (64.2 per cet; 232/361) either always or early always wore their helmets; this decreased to 38.3 per cet of older cyclists. Thus Year 10 cyclists were less likely to ow a helmet ad less likely to wear oe if they owed oe. Although girls were less likely to ow helmets tha boys, they were ot less likely tha boys to wear them. Just over a third (36.8 per cet, 232/630) of Year 6 cyclists wore a helmet always or early always; this dropped to 13.7 per cet (184/ 1345 i Year 10 cyclists. Reasos for ot owig or wearig helmets The questioaire suggested a umber of possible reasos for ot owig or wearig a helmet, relatig to appearace, cost ad effort. Childre were asked to tick all the reasos they felt applied to them. Regardig owership, various reasos relatig to appearace, i.e. 'thik I'd look silly wearig oe', 'frieds might laugh' or 'I do't like the look of them' were very importat, but givig the subject o thought ad ot ridig a bicycle very ofte were also very commo reasos give for ot owig a cycle helmet (see Tables 1 ad 2). These reasos were similar for both year groups, but the topreasogive by girl cyclists i both Years 6 ad 10 was that they did ot ride a bicycle very ofte per cet of girl cyclists i Year 6 who did ot wear a helmet gave this as a reaso. Expese was metioed as a factor by 16 per cet of Year 6 cyclists ad 17 per cet of Year 10 cyclists.

3 72 JOURNAL OF PUBLIC HEALTH MEDICINE Year 6 Replies M F Bicycle riders 350 (92) 30 (7.9) 270 (96.4) 10 (3.7) 3 Helmet owers 214 (61.1) 136 (38.9) 147 (54) 123 (45.6) 4 Cycle helmet wearig (Always & Nearly Always) total sample 36.6 (139/380) cycle riders 39.7 (139/350) helmet owers 65.0 (139/214) of total sample 33.2 (93/280) cycle riders 34.4 (93/270) of helmet owers 63.3 (93/147) Year 10 (*) Replies M F Bicycle riders 763 (88.0) 104 (12.0) 582 (78.3) 161 (21.7) 3 Helmet owers 307 (40.2) 456 (59.8) 174 (29.9) 408 (70.1) 4 Cycle helmet wearig (Always & Nearly Always) total sample 13.8 (120/867) cycle riders 15.7 (120/763) helmet owers 39.1 (120/307) of total sample 8.6 (64/743) cycle riders 11.0 (64/582) of helmet owers 36.8 (64/174) Figure 1 Summary of cycle helmet owig ad wearig by age ad sex. Year 6 ad Year 10. The most importat reaso amogst both year groups for ot wearig a helmet if they had oe was that it felt ucomfortable (43 per cet of Year 6 childre ad 45 per cet of Year 10 childre gave this reaso). Appearace was agai importat; thikig they would look silly wearig oe was the secod most importat reaso give by both year groups, ad 39 per cet of Year 10 childre also said they were afraid that their frieds might laugh at them. This was ot so importat to Year 6 childre. Other importat reasos amogst Year 6 childre were forgettig to put the helmet o, ad shortess of the jourey. Shortess of the jourey was also a importat reaso give by Year 10 childre. Few childre (betwee 4 ad 6 per cet i both year groups) thought that a helmet would ot protect them from ijury (see Tables 1 ad 2). Qualitative survey - results offocus groups All the childre i the groups were bicycle riders who geerally rode their bicycles away from busy roads, preferrig to cycle o footpaths, quiet roads, outside their homes or i their gardes. I geeral, the childre did ot feel that they were likely to

4 CYCLE HELMET WEARING 73 Table 1 Reasos for ot owig ad wearig helmets amogst cycle riders, Year 6 childre, by sex (ordered by resposes from total childre) Boys Girl! Total persos Reasos for ot owig a helmet 1 thik I'd look silly wearig oe Never thought about it Do't ride a bike very ofte Frieds might laugh 1 do't like the look of them Too expesive It wo't protect me Jourey too short Reasos for ot wearig a helmet It feels ucomfortable 1 thik I'll look silly wearig oe Forget to put it o Jourey too short Frieds might laugh where to put it whe 1 take it off Difficult to put o/faste 1 do't like the look of them It might get stole It wo't protect me suffer serious ijury i a bicycle accidet. The type of ijuries they perceived themselves to be most at risk from were grazes, broke boes ad head ijuries. Oly oe group perceived themselves as beig at risk of dyig i a accidet. However, despite the lack of perceived risk all of the childre uderstood that a head ijury as a result of a bicycle accidet was the most serious type of ijury, although oe of the childre had ever suffered from a serious head ijury. Three childre did report fallig off their bicycles ad bagig their heads - oly oe child was wearig a helmet Childre who did ow ad wear a helmet believed that it would protect their heads should a accidet occur. However, Table 2 Reasos for ot owig ad wearig helmets amogst cycle riders, Year 10 childre, by sex (ordered by resposes from total childre) Boys Girl* Total persos Reasos for ot owig a helmet Do't ride a bike very ofte I thik I'd look silly wearig oe I do't like the look of them Frieds might laugh Never thought about it Too expesive Jourey too short It wo't protect me Reasos for ot wearig a helmet It feels ucomfortable I thik I'll look silly wearig oe Jourey too short Frieds might laugh I do't like the look of them where to put it whe I take it off Forget to put it o Difficult to put o/faste It might get stole It wo't protect me

5 74 JOURNAL OF PUBLIC HEALTH MEDICINE childre perceived helmets to be more ecessary i what they thought more dagerous coditios: i busy traffic ad off-road cyclig, whe it was raiig or icy, ad o log joureys. Whe discussig reasos for ot wearig a cycle helmet o every jourey the childre believed that they were less ecessary for short joureys or whe cyclig away from busy roads. The mai reasos for ot wearig helmets at all icluded appearace, the difficulty i takig them off, the time it takes to put them o, the heat that is geerated whe wearig oe, the expese of buyig a helmet ad kowig from where to buy them. The appearace ad comfort of the helmet was a major cocer for all the childre, but there were differeces i preferece regardig appearace of helmets. Year 6 childre preferred bright, fluorescet colours, but Year 10 childre preferred black, which they perceived to be less oticeable. Both year groups liked sports logos, but Year 10 childre were ot really iterested i the football teams or pop group motifs which appealed to the youger childre. Both groups thought that legislatio was the oly way to get most childre to wear helmets, because if everyoe had to wear a helmet there would be o embarrassmet ivolved, as everyoe would look the same. Discussio Although the sample was ot radomly selected, the selectio process attempted to address differet populatios across the district ad achieved a good respose ratio. Therefore, there is o reaso to suggest that the results are ot a reliable guide to iform health promotio activity. Bicycle ridig I Year 6, most of the childre were bicycle riders - 92 per cet of males ad 96 per cet of females. By Year 10, the cycle ridig prevalece had dropped to 88 per cet for males ad 78 per cet for females. Thus, over 20 per cet of the girls said they did ot ride a bicycle at all ad over 50 per cet of Year 10 Table 3 Factors ifluecig wearig of cycle helmets Local Paretal ifluece Peer pressure School policies Local road ifrastructure Local health educatio campaigs Socio-demographic characteristics Wider or atioal Legislatio Desig Cost Marketig Natioal health educatio campaig girls said they did ot ride a bicycle very ofte. As the majority of youg people did ride bicycles, this reiforces the fact that schools are a appropriate place to coduct health educatio i the area, but that youger age groups are particularly importat as a higher proportio are at potetial risk. However, although fewer Year 10 childre were cyclig, more of them cycle o busy roads (e.g. to school) ad therefore may be at a higher risk of serious accidet. Cycle helmet owig ad wearig rates Our research showed that uder half of all childre surveyed owed a helmet ad owership decreased with age. Year 10 childre were less likely to ow a helmet tha Year 6 childre, ad eve if they did ow oe they were less likely to wear it tha were Year 6 pupils. Girls were less likely to ow a helmet i both year groups, but although wearig rates amogst all girl cyclists were lower tha amog boys, this was ot the case amogst helmet owers. Although oly 40 per cet of cycle ridig boys ad 34 per cet of cycleridiggirls i Year 6 wore a helmet most of the time, oce a helmet was owed, early twothirds of both boys ad girls always or early always wore it Eve i Year 10, oce a helmet was owed, girls were oly slightly less likely to wear it tha boys, although the percetage had dropped to about oe-third of helmet owers. Therefore, amogst youger groups, efforts to icrease owership seem to result i helmets beig wor. Table 4 (below) summarizes the limited UK research o cycle helmet owership ad wearig to date. The rates vary with differet settigs, ad readers will be able to judge the most appropriate rates for their ow situatios. The high rates idetified i this study may be either due to particular populatio characteristics of the South Staffordshire populatio, such as relative affluece, or a reflectio of the tred of icreasig wearig rates i the Uited Kigdom. Studies suggest that iteratioally ad i the Uited Kigdom wearig rates are icreasig. I the Uited Kigdom, Research Iteratioal UK 4 " 5 reported a large icrease i helmet owership ad wearig rates amogst juior ad secodary school childre betwee 1991 ad The higher wearig rates, especially amogst the youger groups, could partly be explaied by this tred. Reasos for ot owig ad wearig a helmet The differece i owig (ad wearig) rates betwee males ad females is potetially due to the differet patters of cycle use, i.e. girls do ot cycle as much. The top reaso give by girls for ot owig a helmet was that they did ot ride a bike very ofte (both Year 6 ad Year 10) - this may mea that they therefore see themselves at lesser risk of havig a accidet Both year groups kew that helmets have a protective effect ad few gave the fact that helmets would ot protect them as a reaso for ot owig ad wearig a helmet. However, the focus groups revealed that both year groups did ot see

7 76 JOURNAL OF PUBLIC HEALTH MEDICINE Table 5 Issues for cosideratio i local campaigs Expese aloe is ot a factor for most o-helmet owers; multi-agecy campaigs are most effective rather tha those cocetratig o expese aloe Kowledge of the protective effect of helmets is good, but cyclists are less aware of their ow persoal risk, especially for short joureys ad those ot o busy roads t all youg people are regular cycle riders; those who ride a bicycle fall ito differet categories, i.e. by frequecy of cyclig ad by eviromet of cyclig (busy roads, off road oly); these factors affect perceived risk ad for may, especially older girls, this is a importat factor i ot owig or wearig a helmet Older childre's helmet wearig habits are particularty difficult to ifluece Local retailers eed to be ecouraged to stock a wide rage of helmets i styles that appeal to differet age groups; thus maufacturers have a importat role to play by maufacturig helmets i differet types ad styles Maufacturers also eed to be ecouraged to improve the comfort of helmets - ad marketig them as comfortable themselves as beig persoally at risk, ad there was also a geeral feelig that helmets were oly eeded for joureys o busy roads ad were ot eeded for local ad short joureys. This would suggest that messages about geeral safety seem to be gettig across, but attitudes regardig persoal risk ad the eed to wear helmets for short joureys are ot chaged as a result. The factors ifluecig patters of owership ad wearig are umerous (see Table 3) ad the iter-relatioships betwee them are complex. A rage of local ad wider or atioal issues determie idividual perceptios of risks ad beefits relatig to cycle helmet use. Research 5 " 7 has cited perceived poor appearace, poor desig, peer pressure ad cost as reasos most ofte quoted as barriers to owig ad wearig (see Table 4). Our research fidigs show that appearace is importat, but comfort (or lack of comfort) of wearig the helmet is just as importat Lack of thought about wearig a cycle helmet was a frequet reaso give. Health educatio campaigs ca help to raise awareess ad to focus o issues related to perceived appearace ad peer pressure, but maufacturers eed to work o comfort of helmets as well as their appearace ad cost. Our research foud that differet year groups wated differet types of helmet. Year 6 childre wated bright colours ad distictive motifs whereas Year 10 childre wated less cospicuous helmets, usually black. Helmet maufacturers ad retailers eed to provide a choice of helmets to suit both age groups. May past campaigs have cocetrated o expese as a barrier to helmet owig ad thus wearig. Expese was cited as a factor amogst cyclists who were o-helmet owers by oly 13 per cet of boys ad 16 per cet of girls i Year 6, ad 22 per cet of boys ad girls i Year 10. Colyer et al. 8 reported the reasos a group of parets gave for ot providig their childre with helmets; 74 per cet had ever thought of doig so, ad oly 7 per cet said that expese was a factor. I Research Iteratioal's 1995 report, 17 per cet of parets of juior school childre ad 2 per cet of secodary school childre said helmets were too expesive. 7 Lee (persoal commuicatio, 1993) showed that expese was a factor, particularly i more deprived populatios, but more recet data suggest that expese may be of lesser importace tha previously. Therefore, depedig o the settig, schemes pricipally cocetratig o this aspect of promotio are likely to affect a very small proportio of the populatio. The differece i owig ad wearig rates betwee year groups may be due to youger people beig focused o more ofte by campaigs, to their beig subjected to more vigorous paretal pressure to ow ad wear a helmet, or to their beig more receptive to campaigs. I Australia, a campaig directed at mothers of youg childre ad parets of childre less tha 15 years old was evaluated ad it was foud that the campaig made a impact oly o the youger childre (Leicester et al., 1991, reported i Ref. 5). Our study ad that of Lee (persoal commuicatio, 1983) suggest that childre see legislatio as a way of resistig peer pressure agaist helmet wearig. Legislatio i Victoria, Australia, has icreased cycle helmet wearig rates from 4.6 per cet amogst metropolita primary school childre i 1983 to 94 per cet post-legislatio i Amogst secodary school childre post-legislatio wearig rates were 65 per cet (Leicester et al., 1991,reportedi Ref. 5). There is some evidece that legislatio may reduce bicycle usage ad this may cotribute towards the reductio i head ijuries after legislatio. 9 Legislatio appears to be a effective itervetio ad should be cosidered by the British GovermeL The focus groups also idetified the role of adults i ifluecig ad settig a example, both as parets ad as geera] cycle riders. As wearig rates were high amogst helmet owers i Year 6, paretal awareess leadig to purchase is a importat factor. Some issues that orgaizers of local campaigs might wish to cosider are give i Table 5. Coclusio This research has agai demostrated the complemetary ature of qualitative ad quatitative research, by providig useful baselie data together with more i-depth isights ito a importat health promotio area. Cycle helmet owership ad wearig, although icreasig, is still low, especially amogst

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